Provider Demographics
NPI:1700198108
Name:SHELTON, JODI LYNN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3849
Mailing Address - Country:US
Mailing Address - Phone:208-232-2592
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2745
Practice Address - Country:US
Practice Address - Phone:208-232-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-29318104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker